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New Patient Information and Forms | UCSF Transplant Surgery
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<!-- end breadcrumb and search --> <!-- end breadcrumb and search --> <!-- start content and left bar --> <div id="sg_mainContent"> <!-- container to hold the center section left menu and content --> <div id="sg_centerSection"> <!-- include left bar -- had conditionals for display inside macro --> <!-- start center content - if no left bar full width center section --> <div id="sg_centerContentInt" class='full_width_content' > <!-- beginning of center content - add class "full_width_content" if no left bar region --> <div id="sg_int_content"> <!-- child includes go here --> <div id="contentTitle"> <h1>New Patient Information & Forms</h1> </div> <div id="contentBody"> <p class="callout">Please note: This page is only for new kidney transplant patients with a scheduled evaluation appointment.</p> <h2><span><span>Required Forms for Initial Appointment</span></span></h2> <ul> <li><a href="https://www.ucdonor.org/#_" target="_blank">Online Medical History Questionnaire</a> (Please <strong>submit this form</strong> <strong>online</strong> before your appointment)</li> </ul> <p>Please complete and print out the forms and bring them with you to your appointment.</p> <h3>English</h3> <ul> <li><a href="/media/2717934/AUTHORIZATION%20FOR%20RELEASE%20OF%20HEALTH%20INFORMATION.pdf" target="_blank" title=" ">Authorization for Release of Health Information</a></li> <li><a href="/media/2717937/INFORMED CONSENT.pdf" target="_blank" title=" ">Informed Consent To Evaluate</a></li> <li><a href="/media/2655761/876-060e_acknowl_english.pdf" target="_blank" title=" ">Notice of Privacy Practices and Acknowledgment of Receipt</a></li> <li><a style="line-height: 1.4;" href="/media/2717952/multiple_listing.pdf">Questions & Answers for Transplant Candidates about Multiple Listing and Waiting Time Transfer</a></li> <li><a href="/media/2717955/500-0512-rev05-17_final.pdf" target="_blank" title=" ">Terms and Conditions of Service </a></li> </ul> <h3>Español </h3> <ul> <li><a href="/media/10653773/Kidney-Transplant-Authorization-for-Release-of-Health-Information-Spanish-72012.pdf" target="_blank" title=" ">Autorización para la divulgación de información de salud</a><span style="font-size: inherit;"> </span></li> <li><a href="/media/10653779/Kidney-Transplant-Informed-Consent-To-Evaluate-Spanish-92009.pdf" target="_blank" title=" ">Consentimiento informado para evaluarnformed</a></li> <li><a href="/media/10653776/Kidney-Transplant-HIPAA-Spanish-92013.pdf">Aviso de prácticas de privacidad y acuse de recibootice</a></li> <li><a href="/media/10653782/Kidney-Transplant-Questions-Answers-for-Transplant-Candidates-about-Multiple-Listing-and-Waiting-Time-Transfer-Spanish-42018.pdf">Preguntas y respuestas para los candidatos de trasplante sobre el listado múltiple y la transferencia del tiempo de esperau</a></li> <li><a href="/media/10653785/Kidney-Transplant-Terms-and-Conditions-of-Service-Spanish-62017.pdf" target="_blank" title=" ">Términos y condiciones de servicio</a></li> </ul> <h2>Required Forms of Identification</h2> <p>You must have these at the time of your appointment. </p> <ul> <li>Photo ID <strong>(Required)</strong></li> <li>Health Insurance Card <strong>(Required)</strong></li> </ul> <h2><a id="Evaluation Videos" name="Evaluation Videos"></a>Pre-Appointment Videos to Watch</h2> <p>Please watch these videos prior to your appointment.</p> <h3>Kidney Transplant Evaluation</h3> <ul> <li><a href="https://player.vimeo.com/video/53173153">Kidney Transplant Evaluation Presentation</a> (English) </li> <li><a href="https://player.vimeo.com/video/54580564">Presentación de Evaluación de Trasplante de Riñón</a> (Español) </li> <li><a href="https://player.vimeo.com/video/54870305">Kidney Transplant Evaluation Presentation</a> (Cantonese)</li> </ul> <h3>Pancreas Alone and Kidney/Pancreas Transplant</h3> <ul> <li><a href="https://player.vimeo.com/video/315548754">Pancreas Alone and Kidney/Pancreas Transplant</a> (English) </li> <li><a href="https://player.vimeo.com/video/315548717">Solo Páncreas y Trasplante de Riñón/Páncreas</a> (Español)<a href="https://player.vimeo.com/video/315548717"></a></li> <li><a href="https://player.vimeo.com/video/315548805">Pancreas Alone and Kidney/Pancreas Transplant</a> (Cantonese)</li> </ul> <h3>Re-Evaluation Appointment</h3> <ul> <li><a href="https://player.vimeo.com/video/315548743">Re-Evaluation Appointment (English)</a></li> <li><a href="https://player.vimeo.com/video/315548845">Nombramiento de Reevaluación (Español)</a></li> <li><a href="https://player.vimeo.com/video/315548797">Re-Evaluation Appointment (Cantonese)</a></li> </ul> <h2>Living Donor Transplant Program</h2> <ul> <li>Living Donor Transplant Video <a href="https://vimeo.com/147524524">English</a> | <a href="https://vimeo.com/148024556">Spanish</a></li> <li><a href="https://vimeo.com/148024556"></a><a href="https://vimeo.com/147521025">Living Donor Kidney Transplant Video</a> (English)</li> <li><a href="http://vimeo.com/148017011">Vida Video de riñón de donante</a><span style="font-size: inherit;"> (Español)</span></li> <li><a href="http://www.wearetransplant.com/">We Are Transplant: Stories from the Novartis Transplant Games</a><span style="font-size: inherit;"> (Patient Stories)</span></li> </ul> <h2><a id="Educational Materials" name="Educational Materials"></a>Patient Education Materials</h2> <p><span>Please review these prior to your appointment.</span></p> <ul> <li style="font-family: Arial, Helvetica, sans-serif;"><a href="/media/11529703/eval_-_financial_counselor_letterdoc.pdf">Insurance Information About Your Transplant</a> (English)</li> <li style="font-family: Arial, Helvetica, sans-serif;"><a href="/media/5721223/new_patient_eval_letter_final_sp.pdf"><span>Información sobre el seguro de su trasplante</span></a> (Español)</li> <li style="font-family: Arial, Helvetica, sans-serif;"><a href="/media/5721222/new_patient_eval_letter_final_chin.pdf"><span>关于你的移植的保险信息</span></a> (<span>中文</span>) (Chinese)</li> <li style="font-family: Arial, Helvetica, sans-serif;"><a href="/media/2717940/Introduction Your Health Matters.pdf" target="_blank" title=" ">Introduction: Your Health Matters</a></li> <li style="font-family: Arial, Helvetica, sans-serif;"><a href="/media/2717946/3-03ucsfhipaa.pdf" target="_blank" title=" ">Notice of Privacy Practices Brochure</a></li> <li style="font-family: Arial, Helvetica, sans-serif;"><a href="#" target="_blank" title="Patient & Graft Survival">Post-Transplant Outcomes Data</a></li> <li style="font-family: Arial, Helvetica, sans-serif;"><a style="line-height: 1.4;" href="http://www.unos.org/docs/Kidney_Brochure.pdf" target="_blank">Kidney Allocation</a></li> </ul> <h2>Questions and Other Info</h2> <p>Please call: (415) 353-1551</p> <p><strong>UCSF Kidney/Pancreas Transplant Team<br> </strong> Connie Frank Transplant Center<br> University of California, San Francisco<br> Kidney/Pancreas Transplant Services<br> 400 Parnassus Ave. 7th Floor, Suite 701<br> San Francisco, CA 94143-0116</p> </div> <script language="javascript" type="text/javascript" src="/scripts/textarea.js"></script> <!-- end child includes go here --> </div><!-- end sg_int_content --> <!-- this is the content footer - new footer with last publish date possible --> <!-- end content footer --> <!-- hold popouts for local and systemwide programs and labs --> <div id="slideout_programs_labs_panel_surgerywide" class="robby2"> <form> <div id="findAProgramLabSystemWide" xmlns:user="urn:my-scripts"><div class="findAProgramCloseButton"><a href="#"> </a></div><div class="findAProgramHeaderSystemWide"><div class="findAProgramColumnDiv robby4">Site Directory</div><ul class='findAProgramPopoutUL'><li><a href='#'></a></li><li><a href='https://umbracosupport.ucsf.edu/'>Web Support Portal</a></li><li><a href='https://surgerystaff.ucsf.edu/'>Surgery Staff 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